Richard Hobbs

ESC/EAS Guidelines for the management of dyslipidaemias: the Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS)

Cardiovascular disease (CVD) due to atherosclerosis of the arterial vessel wall and to thrombosis is the foremost cause of premature mortality and of disability-adjusted life years (DALYs) in Europe, and is also increasingly common in developing countries.1 In the European Union, the economic cost of CVD represents annually E192 billion1 in direct and indirect healthcare costs. The main clinical entities are coronary artery disease (CAD), ischaemic stroke, and peripheral arterial disease (PAD). The causes of these CVDs are multifactorial. Some of these factors relate to lifestyles, such as tobacco smoking, lack of physical activity, and dietary habits, and are thus modifiable. Other risk factors are also modifiable, such as elevated blood pressure, type 2 diabetes, and dyslipidaemias, or non-modifiable, such as age and male gender. These guidelines deal with the management of dyslipidaemias as an essential and integral part of CVD prevention. Prevention and treatment of dyslipidaemias should always be considered within the broader framework of CVD prevention, which is addressed in guidelines of the Joint European Societies’ Task forces on CVD prevention in clinical practice.2 – 5 The latest version of these guidelines was published in 20075; an update will become available in 2012. These Joint ESC/European Atherosclerosis Society (EAS) guidelines on the management of dyslipidaemias are complementary to the guidelines on CVD prevention in clinical practice and address not only physicians [e.g. general practitioners (GPs) and cardiologists] interested in CVD prevention, but also specialists from lipid clinics or metabolic units who are dealing with dyslipidaemias that are more difficult to classify and treat.

ESC Guidelines for the management of grown-up congenital heart disease (new version 2010).

Guidelines summarize and evaluate all currently available evidence on a particular issue with the aim of assisting physicians in selecting the best management strategies for an individual patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks, and their legal implications have been discussed previously. Guidelines and recommendations should help physicians to make decisions in their daily practice. However, the ultimate judgement regarding the care of an individual patient must be made by his/her responsible physician(s).nnA large number of Guidelines have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for the development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines can be found on the ESC Web Site (http://www.escardio.org/guidelines/rules).nnMembers of this Task Force were selected by the ESC to represent all physicians involved with the medical care of patients in this pathology. In brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. A critical evaluation of diagnostic and therapeutic procedures is performed, including assessment of the risk–benefit ratio. Estimates of expected health outcomes for larger populations are included, where data exist. The level of evidence and the strength of recommendation of particular treatment options are weighed and graded according to pre-defined scales, as outlined in Tablesxa01 and 2 .nnView this table:nnTablexa01 nClasses of recommendationsnnnnView this table:nnTablexa02 nLevels of evidencennnnThe experts of the writing and reviewing panels have provided disclosure statements of all relationships they may have which …

Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery

The American College of Cardiology, American Heart Association, and the European Society of Cardiology are all in the process of completing updated versions of our Guidelines for Perioperative Care. nnOur respective writing committees are undertaking a careful analysis of all relevant validated studies and always incorporate appropriate new trials and meta-analyses into our evidence review. nnIn the interim, our current joint position is that the initiation of beta blockers in patients who will undergo non-cardiac surgery should not be considered routine, but should be considered carefully by each patients treating physician on a case-by-case basis. nnPlease see the expression of concern which is free to view in Eur Heart J (2013) 34 (44): 3460; doi: 10.1093/eurheartj/eht431. nnAAAn: abdominal aortic aneurysmnACCn: American College of CardiologynACEn: angiotensin-converting enzymenACSn: acute coronary syndromenAHAn: American Heart AssociationnARn: aortic regurgitationnARBn: angiotensin receptor blockernASn: aortic stenosisnAFn: atrial fibrillationnBBSAn: β-blocker in spinal anaesthesianBNPn: brain natriuretic peptidenCABGn: coronary artery bypass graftingnCARPn: coronary artery revascularization prophylaxisnCASSn: coronary artery surgery studynCIn: confidence intervalnCOX-2n: cyclooxygenase-2nCOPDn: chronic obstructive pulmonary diseasenCPETn: cardiopulmonary exercise testingnCPGn: Committee for Practice GuidelinesnCRPn: C-reactive proteinnCTn: computed tomographyncTnIn: cardiac troponin IncTnTn: cardiac troponin TnCVDn: cardiovascular diseasenDECREASEn: Dutch Echocardiographic Cardiac Risk Evaluating Applying Stress EchonDESn: drug-eluting stentnDIPOMn: Diabetes Postoperative Mortality and MorbiditynDSEn: dobutamine stress echocardiographynECGn: electrocardiographynESCn: European Society of CardiologynFEV1n: forced expiratory volume in 1 snFRISCn: fast revascularization in instability in coronary diseasenHRn: hazard rationICUn: intensive care unitnIHDn: ischaemic heart diseasenINRn: international normalized rationLMWHn: low molecular weight heparinnLQTSn: long QT syndromenLRn: likelihood rationLVn: left ventricularnMaVSn: metoprolol after surgerynMETn: metabolic equivalentnMIn: myocardial infarctionnMRn: mitral regurgitationnMRIn: magnetic resonance imagingnMSn: mitral stenosisnNICE-SUGARn: normoglycaemia in intensive care evaluation and survival using glucose algorithm regulationnNSTEMIn: non-ST-segment elevation myocardial infarctionnNT-proBNPn: N-terminal pro-brain natriuretic peptidenNYHAn: New York Heart AssociationnOPUSn: orbofiban in patients with unstable coronary syndromesnORn: odds rationPaCO2n: mixed expired volume of alveolar and dead space gasnPAHn: pulmonary arterial hypertensionnPETCO2n: end-tidal expiratory CO2 pressurenPCIn: percutaneous coronary interventionnPDAn: personal digital assistantnPOISEn: PeriOperative ISchaemic Evaluation trialnQUO-VADISn: QUinapril On Vascular ACE and Determinants of ISchemianROCn: receiver operating characteristicnSDn: standard deviationnSMVTn: sustained monomorphic ventricular tachycardianSPECTn: single photon emission computed tomographynSPVTn: sustained polymorphic ventricular tachycardianSTEMIn: ST-segment elevation myocardial infarctionnSVTn: supraventricular tachycardianSYNTAXn: synergy between percutaneous coronary intervention with taxus and cardiac surgerynTACTICSn: treat angina with aggrastat and determine cost of therapy with an invasive or conservative strategynTIAn: transient ischaemic attacknTIMIn: thrombolysis in myocardial infarctionnTOEn: transoesophageal echocardiographynUFHn: unfractionated heparinnVCO2n: carbon dioxide productionnVEn: minute ventilationnVHDn: valvular heart diseasenVKAn: vitamin K antagonistnVO2n: oxygen consumptionnVPBn: ventricular premature beatnVTn: ventricular tachycardiannGuidelines and Expert Consensus Documents aim to present management and recommendations based on the relevant evidence on a particular subject in order to help physicians to select the best possible management strategies for the individual patient suffering from a specific condition, taking into account not only the impact on outcome, but also the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously.1nnA great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and also by other organizations or related societies. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC guidelines and Expert Consensus Documents can be found on the ESC website in the guidelines section (www.escardio.org).nnIn brief, experts in the field are selected and undertake a comprehensive review of the published evidence for management and/or prevention of a given condition. …

European guidelines on cardiovascular disease prevention in clinical practice (version 2012) : the fifth joint task force of the European society of cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of nine societies and by invited experts).

Atherosclerotic cardiovascular disease (CVD) is a chronic disorder developing insidiously thoughout life and usually progressing to an advanced stage by the time symptoms occur. It remains the major cause of premature death in Europe, even though CVD mortality has fallen considerably over recent decades in many European countries. It is estimated that .80% of all CVD mortality now occurs in developing countries. CVD causes mass disability: within the coming decades the disability-adjusted life years (DALYs) estimate is expected to rise from a loss of 85 million DALYs in 1990 to a loss of x02150 million DALYs globally in 2020, thereby remaining the leading somatic cause of loss of productivity.

European Guidelines on cardiovascular disease prevention in clinical practice (version 2012)

European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) : the Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts).

The Euro Heart Failure Survey of the EUROHEART survey programme. A survey on the quality of care among patients with heart failure in Europe

The EUROHEART programme is a rolling programme of cardiovascular surveys among the member nations of the European Society of Cardiology (ESC). These surveys will provide information on the nature of cardiovascular disease and its management. This manuscript describes a survey into the nature and management of heart failure.

Randomised controlled feasibility trial of a web-based weight management intervention with nurse support for obese patients in primary care

BackgroundThere is a need for cost-effective weight management interventions that primary care can deliver to reduce the morbidity caused by obesity. Automated web-based interventions might provide a solution, but evidence suggests that they may be ineffective without additional human support. The main aim of this study was to carry out a feasibility trial of a web-based weight management intervention in primary care, comparing different levels of nurse support, to determine the optimal combination of web-based and personal support to be tested in a full trial.MethodsThis was an individually randomised four arm parallel non-blinded trial, recruiting obese patients in primary care. Following online registration, patients were randomly allocated by the automated intervention to either usual care, the web-based intervention only, or the web-based intervention with either basic nurse support (3 sessions in 3xa0months) or regular nurse support (7 sessions in 6xa0months). The main outcome measure (intended as the primary outcome for the main trial) was weight loss in kg at 12xa0months. As this was a feasibility trial no statistical analyses were carried out, but we present means, confidence intervals and effect sizes for weight loss in each group, uptake and retention, and completion of intervention components and outcome measures.ResultsAll randomised patients were included in the weight loss analyses (using Last Observation Carried Forward). At 12xa0months mean weight loss was: usual care group (nu2009=u200943) 2.44xa0kg; web-based only group (nu2009=u200945) 2.30xa0kg; basic nurse support group (nu2009=u200944) 4.31xa0kg; regular nurse support group (nu2009=u200947) 2.50xa0kg. Intervention effect sizes compared with usual care were: du2009=u20090.01 web-based; du2009=u20090.34 basic nurse support; du2009=u20090.02 regular nurse support. Two practices deviated from protocol by providing considerable weight management support to their usual care patients.ConclusionsThis study demonstrated the feasibility of delivering a web-based weight management intervention supported by practice nurses in primary care, and suggests that the combination of the web-based intervention with basic nurse support could provide an effective solution to weight management support in a primary care context.Trial registrationCurrent Controlled Trials ISRCTN31685626.

An internet-based intervention with brief nurse support to manage obesity in primary care (POWeR+): a pragmatic, parallel-group, randomised controlled trial

BACKGROUNDnThe obesity epidemic has major public health consequences. Expert dietetic and behavioural counselling with intensive follow-up is effective, but resource requirements severely restrict widespread implementation in primary care, where most patients are managed. We aimed to estimate the effectiveness and cost-effectiveness of an internet-based behavioural intervention (POWeR+) combined with brief practice nurse support in primary care.nnnMETHODSnWe did this pragmatic, parallel-group, randomised controlled trial at 56 primary care practices in central and south England. Eligible adults aged 18 years or older with a BMI of 30 kg/m(2) or more (or ≥28 kg/m(2) with hypertension, hypercholesterolaemia, or diabetes) registered online with POWeR+-a 24 session, web-based, weight management intervention lasting 6 months. After registration, the website automatically randomly assigned patients (1:1:1), via computer-generated random numbers, to receive evidence-based dietetic advice to swap foods for similar, but healthier, choices and increase fruit and vegetable intake, in addition to 6 monthly nurse follow-up (control group); web-based intervention and face-to-face nurse support (POWeR+Face-to-face [POWeR+F]; up to seven nurse contacts over 6 months); or web-based intervention and remote nurse support (POWeR+Remote [POWeR+R]; up to five emails or brief phone calls over 6 months). Participants and investigators were masked to group allocation at the point of randomisation; masking of participants was not possible after randomisation. The primary outcome was weight loss averaged over 12 months. We did a secondary analysis of weight to measure maintenance of 5% weight loss at months 6 and 12. We modelled the cost-effectiveness of each intervention. We did analysis by intention to treat, with multiple imputation for missing data. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN21244703.nnnFINDINGSnBetween Jan 30, 2013, and March 20, 2014, 818 participants were randomly assigned to the control group (n=279), the POWeR+F group (n=269), or the POWeR+R group (n=270). Weight loss averaged over 12 months was recorded in 666 (81%) participants. The control group lost almost 3 kg over 12 months (crude mean weight: baseline 104·38 kg [SD 21·11; n=279], 6 months 101·91 kg [19·35; n=136], 12 months 101·74 kg [19·57; n=227]). The primary imputed analysis showed that compared with the control group, patients in the POWeR+F group achieved an additional weight reduction of 1·5 kg (95% CI 0·6-2·4; p=0·001) averaged over 12 months, and patients in the POWeR+R group achieved an additional 1·3 kg (0·34-2·2; p=0·007). 21% of patients in the control group had maintained a clinically important 5% weight reduction at month 12, compared with 29% of patients in the POWeR+F group (risk ratio 1·56, 0·96-2·51; p=0·070) and 32% of patients in the POWeR+R group (1·82, 1·31-2·74; p=0·004). The incremental overall cost to the health service per kg weight lost with the POWeR+ interventions versus the control strategy was £18 (95% CI -129 to 195) for POWeR+F and -£25 (-268 to 157) for POWeR+R; the probability of being cost-effective at a threshold of £100 per kg lost was 88% and 98%, respectively. No adverse events were reported.nnnINTERPRETATIONnWeight loss can be maintained in some individuals by use of novel written material with occasional brief nurse follow-up. However, more people can maintain clinically important weight reductions with a web-based behavioural program and brief remote follow-up, with no increase in health service costs. Future research should assess the extent to which clinically important weight loss can be maintained beyond 1 year.nnnFUNDINGnHealth Technology Assessment Programme of the National Institute for Health Research.

Evaluating the effectiveness of GP endorsement on increasing participation in the NHS Bowel Cancer Screening Programme in England: study protocol for a randomized controlled trial

BackgroundThe success and cost-effectiveness of bowel cancer screening depends on achieving and maintaining high screening uptake rates. The involvement of GPs in screening has been found to improve patient compliance. Therefore, the endorsement of screening by GPs may increase uptake rates amongst non-responders.Methods/DesignA two-armed randomised controlled trial will evaluate the effectiveness of a GP endorsed reminder in improving patient participation in the NHS Bowel Cancer Screening Programme (NHSBCSP). Up to 30 general practices in the West Midlands with a screening uptake rate of less than 50% will be recruited and patients identified from the patient lists of these practices. Eligible patients will be those aged 60 to 74, who have previously been invited to participate in bowel screening but who have been recorded by the Midlands and North West Bowel Cancer Screening Hub as non-responders. Approximately 4,380 people will be randomised in equal numbers to either the intervention (GP letter and duplicate FOBt kit) or control (no additional contact) arms of the trial.The primary outcome measure will be the difference in the uptake rate of FOBt screening for bowel cancer between the intervention and control groups at 13 weeks after the GP endorsed reminder and duplicate FOBt kit are sent. Secondary outcome measures will be subgroup analyses of uptake according to gender, age and deprivation quartile, and the validation of methods for collecting GP, NHSBCSP and patient costs associated with the intervention. Qualitative work (30 to 40 semi-structured interviews) will be undertaken with individuals in the intervention arm who return a FOBt kit, to investigate the relative importance of the duplicate FOBt kit, reminder to participate, and GP endorsement of that reminder in contributing to individuals decisions to participate in screening.DiscussionImplementing feasible, acceptable and cost-effective strategies to improve screening uptake amongst non-responders to invitations to participate is fundamentally important for the success of screening programmes. If this feasibility study demonstrates a significant increase in uptake of FOBt screening in individuals receiving the intervention, a definitive, appropriately powered future trial will be designed.Trial registration numberISRCTN: ISRCTN86784060

Main messages for primary care from the 2016 European Guidelines on cardiovascular disease prevention in clinical practice

Abstract In 2016, a new version of the European Guidelines on Cardiovascular Prevention was released, representing a partnership between the European Association for Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology (ESC) and nine European societies, including Wonca-Europe. The ESC guidelines underscore the importance of a lifetime approach to cardiovascular (CV) risk since both CV risk and prevention are dynamic and continuous as patients’ age and/or accumulate co-morbidities. Healthy people of all ages should be encouraged to adopt a healthy lifestyle, as well as improved lifestyle and reduced risk factor levels are paramount in patients at increased risk of developing cardiovascular disease (CVD) and in those with established CVD. Healthcare professionals, and especially general practitioners, play an important role in helping patients achieve this and should set a personal example of healthy lifestyle behaviour. The ESC guidelines are based on ‘to do’ and ‘not to do’ messages. Of note, what remains uncertain is stated at the end of each dedicated chapter, confirming that guidelines are not absolute rules, and should be interpreted in the light of the healthcare worker’s knowledge and experience, patient preferences and the local social, cultural and economic situation.